Referral form

Please note, Samaritans will endeavour to call the individual as close as possible to their preferred time of contact. Please let the individual know that calls from Samaritans come through on a withheld number. If they have a phone that blocks withheld numbers they will need to remove this setting in order to receive a call from Samaritans.
Samaritans will make up to 3 attempts to call the individual.

Please tick this box to confirm the patient has given consent for their details to be passed to Samaritans and that you have informed them that Samaritans privacy statement can be found on their website.